Mirabel Lodge

87465 Incidental Medical and Dental Care (a) A plan for incidental medical and dental care shall be developed by each facility. The plan shall encourage routine medical and dental care and provide for assistance in obtaining such care, by compliance with the following: (1) The licensee shall arrange, or assist in arranging, for medical and dental care appropriate to the conditions and needs of residents. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that staff did not provide the care that was required for R1, which poses an immediate health, safety or personal rights risk to persons in care.

§1569.69 Employees assisting residents with self-administration of medication; training requirements (a)(1) In facilities licensed to provide care for 16 or more persons, the employee shall complete 24 hours of initial training. This training shall consist of 16 hours of hands-on shadowing training which shall be completed prior to assisting with the self-administration of medications, and 8 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first four weeks of employment. This requirement not met by licensee as evidenced by: Based on LPA record review, current documentation of medication training or medication shadow training not present for S3, which poses an potential health, safety or personal rights risk to persons in care.

87411 Personnel Requirements - General (a) Facility personnel shall at all times be sufficient in numbers, and competent to provide the services necessary to meet resident needs...for the provision of adequate services. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that R1 received timely medical attention, which poses an immediate health, safety or personal rights risk to persons in care.

87465 Incidental Medical and Dental Care (d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration provided all of the following requirements are met...This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility does not use PRN MARs for documenting the administration of PRN medication, which poses a potential health, safety or personal rights risk to persons in care.

87211 Reporting Requirements (a) Each licensee shall furnish... (1)A written report shall be submitted to the licensing agency and to the person responsible for the resident within seven days of the occurrence of any of the events specified in (A) through (D) below. This report shall include the resident's name, age, sex and date of admission; date and nature of event; attending physician's name, findings, and treatment, if any; and disposition of the case. (A) Death of any resident from any cause regardless of where the death occurred, including but not limited to a day program, a hospital, en route to or from a hospital, or visiting away from the facility. This requirement not met by licensee as evidenced by: Based on LPA record review and interview, the licensee did not comply with the section cited above in that facility could not show that facility did not notify R1's PCP via a method of communication shown to be received which poses a potential health, safety or personal rights risk to persons in care.

Type A - 87465 (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication...the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met as evidenced by: Based on records review and interviews with staff, there is a written order from a physician dated 12/20/24 indicating the need for gait belt shall be utilized daily to assist R1 with transfers, but staff (S1 & S2) interviews revealed that they do not use gait belts with none of residents in care, which poses an immediate risk to the health and safety of clients in care

Type A - §1569.269 Enumerated rights; severability (a) Residents of RCFE shall have all of the following rights: (1) To be accorded dignity in their personal relationships with staff, residents, and other people. This requirement has not been met as evidence by: Based on LPA’s observations and interviews with staff, the facility staff assisted residents in care using inappropriate comments and not notifying the residents of their intentions when performing transfers, which poses an immediate risk to the health and safety of clients in care.

Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in one out of three call alert staff did not repond timely to call monitors due to system was off which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/staff observation, interview and record review, the licensee did not comply with the section cited above in 2 out of 27 staff were cleared, but they were not associated to facility which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation and interview, the licensee did not comply with the section cited above by having unpacked dry goods with no expiration dates noted which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/staff observation, interview and record review, the licensee did not comply with the section cited above in two out of five residents were not given their medications as prescribed which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in bathroom toilet in room 7 found cracked and staff placed out of order sign, sticky floor observed throughout facility and trash can with no lid was observed in bathroom room 20, Bathroom in room 12 observed with feces on floor in shared bathroom which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs/staff observation and interview, the licensee did not comply with the section cited above in No toilet paper or paper towels found in residents room which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs/staff observation, interview and record review, the licensee did not comply with the section cited above in all fire extinguishers were expired as February 2024 and two out of nine residents are bedridden which poses an immediate health, safety or personal rights risk to persons in care.

Type A- 87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. Based on interviews with staff and records review Licensee did not ensure proper management of medication by staff did not give R1’s their dosage of Seroquel 150mg as prescribed by their physician’s, which poses an immediate risk to the health & safety of residents in care.

Type A 87203 Fire Safety: All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement has not been met as evidence by: Based on records obtained and interviews conducted with licensee, the licensee did not comply by not ensuring the ability of residents to exit, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee observed storage cabinets containing potentially toxic chemicals unlocked in two communal restrooms. Aerosol hair products in drawer were observed in communal area and readily accessible to residents. Additionally, the laundry room door was observed unlocked and unattended with cleaning and laundry chemicals readily accessible to residents in care, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 3 out of 5 staff (S1, S2 & S3) do not have annual required training hours completed, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above by not having dated menus on file, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee observed expired canned goods, unpacked dry good not with expiration dates noted, and uncovered prepared foods in the walk-in refrigerator. The licensee did not comply with the section cited above which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation, interview and record review, the licensee did not comply with the section cited above in 4 out of five residents (R1, R2, R3 and R4) needs their care plan to be updated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation, records review and interview with Licensee, the licensee did not comply with the section cited above in spot check of medications were conducted and 4 out 5 residents (R1, R2, R3 & R4) medications were not given to residents according to their physician's order, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee observed auditory emergency signal system not working or lacking in 4 out of the 12 client bedrooms inspected, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee measured hot water in one resident bedroom tested was 131.6 F degrees which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee observation and interviews the licensee did not comply with the section above two rusty shower chairs, holes in resident bedroom screen, two faucets broken in resident bedrooms, urine smell in resident room, ceiling fans observed covered with thick layer of dust, cement ramp not flush with cement walkway where residents walk, sticky floors in dining area, trash cans without lids/covers, lights not working, and broken electrical plate in resident room, which poses an immediate health, safety or personal rights risk to persons in care.

Based on LPAs/Licensee had a discussion regarding activities were not occurring during scheduled times. The licensee did not comply with the section cited above by not having any activities during LPA's visit which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in auditory alarms on several resident bedroom sliding glass door exits were not activated, which poses/posed a potential health, safety or personal rights risk to persons in care.

Based on LPA's/Licensee observation and interview, the licensee did not comply with the section cited above in communal area and in one resident bedroom, there was a wheel chair stored in front of sliding glass door, obstructing the exit.which poses an immediate health, safety or personal rights risk to persons in care. As a result of the fire clearance violation, an immediate civil penalty in the amount of $500 is issued today.

87465 Incidental Medical and Dental Care (c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for nonprescription PRN medication but can communicate his/her symptoms clearly, facility staff designated by the licensee shall be permitted to assist the resident with self-administration, provided all of the following requirements are met: (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement has not been met as evidence by: Based on interviews with staff and records review Licensee did not ensure proper management of medication by medication technician staff (S1) who are responsible for medication management of all residents in care which poses an immediate risk to the health & safety of residents in care.

Based on LPA/Lead staff observation, interview and record review, the licensee did not comply with the section cited above in 29 out of 29 admission agreements were not updated after change of ownership indicating the changes including to the use of surveillance cameras in the common areas which poses a potential health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above in four out of six resident's bathrooms 123.8, 118.6, 121.6, 122.4, 108.1, and 127.9 degrees which poses an immediate health, safety or personal rights risk to persons in care.

Based on observation, the licensee did not comply with the section cited above, LPA/lead staff observed missing face cover plate in room# 7, bathroom in room #6 has an out of order sign, there are two drawers missing in shared bathroom for room# 4 and 5 which poses an immediate health, safety or personal rights risk to persons in care.